ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY

Vol. 50 No. 4, 2009

1. VEGF and VEGFRs expression in oral squamous cell carcinoma

Cl. Margaritescu, D. Pirici, Cristiana Simionescu, L. Mogoanta, M. Raica, A. Stinga, Raluca Ciurea, A. Stepan, Alina Stinga, D. Ribatti

Oral cancer is an important cause of worldwide morbidity and mortality, with substantial economic, physiological, and psychosocial impacts due to its treatment modality and a great risk for recurrences and second primary oral squamous cell carcinomas (OSCC) development. Therefore, it is very important to understand the underlying cell biology of such tumors. It is now a well-accepted fact that angiogenesis is essential for the growth and metastasis of solid tumors, including head and neck squamous cell carcinoma. The main factor responsible for angiogenesis is VEGF and its receptors. It has been demonstrated that VEGFRs are also present on tumor cells themselves and other cells from the tumor microenvironment, in addition to tumoral endothelial cells (ECs). Therefore between these cells take place numerous and different interactions mediated via paracrine/autocrine pathways that promote angiogenesis, uncontrolled tumor proliferation and metastasation. In consequence, estimation of VEGF expression and its receptors became a reliable prognostic tool in OSCCS, predicting the poor disease-free survival, poor overall survival, and metastatic disease. Understanding the distribution and role of VEGF and its receptors in the progression of OSCC will be essential to the development and design of new therapeutic strategies.

Corresponding author: Claudiu Margaritescu, MD, PhD, e-mail: c_margaritescu2000@yahoo.com

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2. Aspects of placental morphogenesis and angiogenesis

Carmen Mihaela Mihu, S. Susman, D. Rus Ciuca, D. Mihu, N. Costin

Placental morphology and vascularization are important stages in the evolution of pregnancies. Placental morphogenesis and angiogenesis processes are studied by two-dimensional, three-dimensional and Doppler ultrasound. Ultrasound methods provide important data on the physiology and pathophysiology of fetal-placental exchange. The macroscopic and microscopic study of the placenta brings valuable information on the possible structural changes and implicitly allows assessing fetal-placental circulation. The ultrasound and microscopic evaluation of the placenta are complementary means of examination for the assessment of fetal-maternal exchange. These methods of investigation can be applied in the context of a strict knowledge of placental morphogenesis and angiogenesis.

Corresponding author: Carmen Mihaela Mihu, MD, PhD, e-mail: carmenmihu2004@yahoo.com

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3. This article has been retracted

This article has been retracted

This article has been retracted

Corresponding author: This article has been retracted

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4. Irritated seborrheic keratosis with coarse keratohyalin granules

A. Fernandez-Flores

Aims: The viral etiology of certain types of seborrheic keratosis (SK) has been a controversial subject in literature, with different molecular results. On the contrary, to the molecular approach, some have suggested that certain types of SK are indeed warts, due to their morphologic features. We decided to investigate the presence of coarse keratohyalin granules in cases of irritated SK. Material, Methods and Results: We examined the last 60 cases with such a diagnosis in our Service of Anatomic Pathology and found these granules in eight cases (7.5%). The granules were evidenced in squamous eddies in four cases, while they were seen in foci of hypergranulosis from the top part of the epidermis in five cases. These granules were evidenced in a few foci in three cases while they were seen in multiple foci in five cases. In these eight cases, we also looked for other morphologic signs suggesting a viral origin, such as papilated, exo-endophytic configuration, parakeratosis at the tips of digitations, dilated vessels in the papillae and koilocytes. While six cases presented at least any of these other features, in two of the eight cases (25%), the only clue suggesting a viral origin was the evidence of the thick granules of keratohyalin. Conclusions: We discuss the meaning of such a finding as described in literature, and conclude that it should be a specific feature to look out for, in cases of irritated SK, in order to exclude a diagnosis of verruca vulgaris.

Corresponding author: Angel Fernandez-Flores, MD, PhD, e-mail: gpyauflowerlion@terra.es

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5. Identification of lymphatic vessels and prognostic value of lymphatic microvessel density in lesions of the uterine cervix

L. Saptefrati, Anca Maria Cimpean, A. Ciornii, Raluca Ceausu, N. Esanu, M. Raica

Incomplete characterization of the uterine cervix cancer from molecular point of view represents the main problem for the use of a proper therapy in this disease. Few data are available about D2-40 expression in lymphatic endothelial cells and also in tumor cells from uterine cervix cancer. The aim of the present work was to study the involvement of lymphatics in prognosis and tumor progression of the uterine cervix lesions. We used D2-40 immunostaining to highlight lymphatic vessels from squamous cell metaplasia (n=17), cervical intraepithelial neoplasia (n=11), carcinoma in situ (n=3), microinvasive carcinoma (n=4) and invasive carcinoma (n=19) using Avidin-Biotin technique (LSAB+). Type and distribution of lymphatics in different lesions of the cervix were analyzed. We found significant correlation between lymphatic microvessel density and tumor grade and particular distribution of the lymphatics linked to histopathologic type of the lesions. Also, differences was found in lymphovascular invasion interpretation between routine Hematoxylin and Eosin staining specimens and immunohistochemical ones. Our results showed differences in the distribution and D2-40 expression in lymphatic vessels and tumor cells from the cervix lesions linked to histopathology and tumor grade.

Corresponding author: Marius Raica, MD, PhD, e-mail: raica@umft.ro

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6. Differential diagnosis between chronic granulocytic leukemia, polycythaemia vera and essential thrombocythemia using micro- and ultrastructural measurement data performed at the level of megakaryocyte

R. Schelker, A. Florea, Laura Urian, Mariana Patiu, L. Petrov

The common features of chronic myeloproliferative disorders (CMDs) make the differential diagnosis on clinical or paraclinical basis to become more difficult, and validate the requirements for new methods of detailed diagnosis. Besides the cytogenetic methods, the megakaryocyte (MK) morphology is a valuable element of diagnosis included in the recent "en vogue" criteria. The purpose of this paper is to compare different morphological parameters in MKs from patients diagnosed with three CMDs and to establish a differential diagnosis of these disorders. Studies were performed on smears of bone marrow blood - for light microscope analysis -, and bone marrow biopsies - for transmission electron microscope (TEM) analysis - collected from six patients, two diagnosed with chronic granulocytic leukemia (CGL), two with polycythaemia vera (PV), and other two with essential thrombocythemia (ET). On the light microscope images, we observed important differences between the sizes of MKs and of MKs nuclei in CGL, PV, and ET. On the TEM images, we also noted important differences concerning the size and the aspect of nuclei, aspect of mitochondria, the amount and distribution of RER, Golgi apparatus and demarcation membrane system; the most important are the differences recorded in the number, distribution and sizes of vacuoles, alpha-granules and of the dense bodies. This study provides evidence that there are significant morphological differences between the cellular structures in the MKs from the patients with diagnosed with different CMDs, and thus sustains the utilization of this approach for establishing the differential diagnosis of CMDs.

Corresponding author: Adrian Florea, Biol, PhD, e-mail: aflorea@umfcluj.ro, adrian_a_florea@yahoo.com

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7. Clinical and cytopathological aspects in phyllodes tumors of the breast

Anca Patrascu, Carmen Florina Popescu, I. E. Plesea, Adriana Badulescu, Florentina Tanase, Garofita Mateescu

The frequency of mesenchymal breast tumors is very low, being represented mostly by tumors with biphasic proliferation (phyllodes tumors) and less by other types of non-epithelial tumors. From clinical point of view, phyllodes tumors (PT) can mimic a breast carcinoma. Therefore, the preoperative diagnosis by cytological examination on material obtained by fine needle aspiration (FNA) is very important for adequate treatment of these tumors. In current study, we assessed clinical aspects of 79 phyllodes tumors regarding patient's age and localization of the tumors. In 17 out of 79 cases, it has been performed FNA within the tumors with further cytological examination on the smears obtained. The median age of the patients was 46.07-year-old, being progressively higher with grade of the tumors with significant values between benign and borderline tumors (p=0.04954) and between benign and malignant ones (p=0.02890). The distinguish on the smears of stromal fragments and naked stromal nuclei with variable grade of atypia regarding the tumoral type, in detriment of epithelial elements have been conclusive for fibroepithelial lesion as cytopathological diagnosis. The preoperative differentiation between a breast phyllodes tumor and a breast carcinoma is extremely important for avoiding of a useless radical surgery for the patient. If the fine needle aspiration was correctly performed, the accuracy of the cytodiagnosis has been 82% in current study.

Corresponding author: Carmen Florina Popescu, MD, PhD, e-mail: cpopescu67ro@yahoo.com

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8. The value of the reprocessing method of paraffin-embedded biopsies for transmission electron microscopy

Rodica Lighezan, Flavia Baderca, Aurora Alexa, M. Iacovliev, Diana Bonte, Elena Doina Murarescu, Adriana Nebunu

Transmission electron microscopy (TEM) implies an elaborate preparation protocol that includes: fixation in glutaraldehyde followed by osmium tetraoxide postfixation, specimen dehydration, infiltration, resin embedding, ultrathin sectioning and staining with heavy metal salts. The aim of TEM is to examine the ultrastructure of specimens in ways that cannot be examined using other equipments or techniques. In some cases, when the requirement for TEM were made after tissue collection, useful information can be obtained from reprocessing the formalin-fixed, wax-embedded tissue used for light microscopy.

Corresponding author: Rodica Lighezan, MD, PhD, e-mail: rodalighezan@yahoo.com

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9. Past experience of SUUB's Pathology Department in classic based cervico-vaginal cytology

Anca Mihaela Lazaroiu, Maria Comanescu, V. Moldovan, Diana Secara, Monica Cirstoiu, Maria Sajin, M. Stoian, Gabriela Anton

The importance of screening to detect early lesions that may soon turn into cervical carcinoma is well known. The Romanian contribution to the diagnosis of these lesions dates back over a century ago and is due to A. Babes (1926 and later in the standardization of the Papanikolaou 1928). The experience of the Cytology Compartment of the University Emergency Hospital in Bucharest increased permanently regarding smears made conventionally and those in liquid medium. We believe that this experience should be statistically analyzed and compared with the histological results, especially for the cases of high-grade intraepithelial neoplastic lesions. The article scholastically presents the activity of SUUB's Cytology Compartment, our cases arising mostly from Departments of Gynecology and from medical or surgical emergency cases that were considered at risk by SUUB's clinicians. Our study is based on conventional based Pap test cervico-vaginal cytology activity reports of SUUB's Pathology Department from the past 23 months - 9730 cases -, using Bethesda 2001 system, including descriptive statistics parameters by age, year period, and diagnostic categories. The authors make a detailed description of the pool, enumerating its epidemiological attributes for a future comparative analysis CBP versus LBP - the current technical procedure in SUUB's Cytology Compartment.

Corresponding author: Anca Mihaela Lazaroiu, MD, PhD, e-mail: amarlaz@yahoo.com

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10. Correlations between the changes in patients' dental-facial morphology at the end of the orthodontic treatment and the psychological variables

Ligia Vaida, Adriana Pirte, Claudia Corega, D. Slavescu, Gabriela Mutiu

The purpose of this research was to assess the impact that the improvement of patients' dental-facial morphology has at the end of the orthodontic treatment upon the following psychological variables: self-esteem, current self-related thoughts as well as upon the variables of social self-esteem and performance. The number of patients included in the study was of 168 (82 children and 86 adolescents) who carried out the orthodontic treatment. At the end of the active treatment, we applied to all patients the assessment instruments for the level of self- esteem and self-related current thoughts: the Rosenberg's Self-Esteem Scale and the Heatherton & Polivy Current Thoughts Scale. As far as the patients in the study are concerned, the improvement of their facial aspect at the end of the treatment showed a significantly positive correlation with the variables of global self-esteem, self-related current thoughts, social self-esteem and performance, with the exception of the girls in children study group who showed no correlations between physical aspect and the performance variable.

Corresponding author: Ligia Vaida, DDS, PhD, e-mail: ligia_vaida@yahoo.com

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11. Correlations between gonadotropins level, vaginal cytology and menopause vessel-active phenomena

Madalina Manea, Carmen Florina Popescu, P. Mitrut

Introduction: Vessel active phenomena from menopause as hot flushes have unknown cause but is demonstrated that the hormone substitution treatment has a very good efficiency in the disproof of the symptomatology. Objectives: To establish if there is a correlation between gonadotropins level, the presence of the vessel active manifestations and the atrophy of the vaginal epithelium in menopause. Material and Methods: The study design is cross-sectional, done on the 40 and 60-year-old women from the general population list of a family doctor. We studied the blood values of LH and FSH and the vagina cytology and the relations of these parameters with the presence of hot flushes and others vessel active phenomena in menopause. Results: The group consists of 136 women aged between 40 and 60-year-old. Their blood tests prove: LH with normal levels in 79% of cases, FSH has high values in 85%, the vagina cytology marked out the epithelium atrophy in 76% of cases. Discussion: The augmentation of the FSH values is associated with the presence of hot flashes. The ratio LH/FSH under 0.40 is strong associated with vessel active phenomena (p-value 0.000012). We could not establish a statistical correlation between the presence of the vessel active phenomena and vagina atrophy (p-value 0.098). Conclusions: Vessel active manifestations on the menopause have morphological substratum. The increase of FSH is statistic correlated to the vessel active disorders. It is possible that FRH be the trigger for the hypothalamic thermo detection.

Corresponding author: Madalina Manea, MD, PhD, e-mail: madalinamanea2005@yahoo.com

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12. Myofibroblasts reaction in urothelial carcinomas

Aurora Alexa, Flavia Baderca, Rodica Lighezan, D. Izvernariu

The myofibroblast is a connective tissue cell with intermediate features between the fibroblast and the smooth muscle cell and unknown origin, which normally is present in only a few organs, but with increased incidence in malignancies. The patterns of myofibroblastic reaction may be synchronous, metachronous and mixed. The presence of the myofibroblasts has been demonstrated into the stroma of breast carcinomas, particularly in firm, retracted tumors with no inflammatory infiltrate. The present literature lacks data regarding the presence and the behavior of the myofibroblasts in urothelial carcinomas. Fifty-nine urothelial carcinoma specimens from patients admitted into the Urology Clinic of the Emergency County Hospital of Timisoara between 1999 and 2004 were stained with usual HE stain for the morphological diagnosis and immunohistochemically stained with smooth muscle actin, vimentin, and desmin for the detection of myofibroblasts. In biopsies sampled from normal urinary bladder and in urothelial carcinomas of the superior urinary tract Ta, we have not noticed any cells with myofibroblast morphology or immunophenotype. In Ta tumors, no matter the differentiation grade, we have not noticed myofibroblasts neither between the tumor cells nor at distance. The myofibroblasts were identified in seven of the 26 (26.92%) tumors in T1 stage. In T2 and T3 stage tumors the number of myofibroblasts differs from case to case, being significantly higher in tumors with high differentiation grade, G3.

Corresponding author: Dragos Izvernariu, MD, e-mail: dragos_izve@yahoo.com

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13. Risk factors related to omphalocele and gastroschisis

Lidia Chircor, Rodica Mehedinti, Mihaela Hincu

Omphalocele and gastroschisis are recognized as congenital malformations with a high mortality. Only 60% of children with such malformations survive until the end of the first year of age. It has been suggested that omphalocele and gastroschisis are associated with other congenital malformations, concerning the bones, the heart and the kidney. The aim of the present study is to determine the risk factors in 12 omphalocele and four gastroschisis cases diagnosed and surveyed in the last four years (November 2003-November 2007) at the Emergency County Hospital of Constanta. In 10 of the 16 cases of the studied group, the subjects resulted from spontaneous premature births. None of the cases in the studied group received the maximum APGAR score, values varying between 6 and 9. The average birth weight in the studied group is 2100 g, with values between 950 g and 2900 g. Maternal age is between 15-21-year-old. Average maternal age in cases of second-degree gastroschisis is 6.5 years younger than the witness population and in case of first degree is 5.8 years younger. 87.5% of children's mothers in studied group are first time pregnant, first time gestant. The mother's socio-economic status may be a risk factor on the occurrence of omphalocele and gastroschisis. 81.25% of children's mother in the studied group have no own income and half are single (mono-parental families). None of the studied cases had a history of congenitally malformed siblings, but half of the cases in the studied group associate congenital malformations of gastro-intestinal tract, locomotor system, kidneys and/or heart. The abdominal wall defect existing in gastroschisis is accompanied by the delay of the intestinal loops differentiation. In all cases of gastroschisis in the studied group, the thin intestine caliber is higher or equal to the one of the thick intestine, the intestinal loops remained outside the abdominal cavity have an aspect characteristic to the fifth month of fetal life.

Corresponding author: Lidia Chircor, MD, PhD, e-mail: lidia-chircor@yahoo.com

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14. Predictive value of cellular immune response in cervical cancer

E. Ancuta, Codrina Ancuta, F. Zugun-Eloae, Cristina Iordache, Rodica Chirieac, E. Carasevici

Despite recent advances in the immune mechanisms of cervical cancer (CC), the relapse still remains an actual issue and recognition of new predictive biomarkers is essential. Aim: The purpose of this retrospective study was to investigate possible differences in the primary, in situ, cellular immune response between cervical carcinoma with and without relapse. Material and Methods: Paraffin-embedded tissue samples from 61 consecutive women with CC (34 with and 27 without relapse) were immunostained for CD3, CD20 and CD45 cells. Immune cell profile densities were further assessed, assigning scores between 0 and 3: "0" meaning the absence of inflammatory infiltrate, "1+" low, "2+" intense and "3+" intense infiltrate with lymphoid follicles. Statistical analysis was performed in SPSS-13 software, p<0.05. Results: Statistically significant intra- and peri-tumoral low numbers of several immune cell subtypes are strongly associated with relapse of disease within three and five years in patients with CC (p<0.05); moreover, statistical significant correlations between immune cells and both free survival (CD3: r=0.382; CD20: r=0.404; CD45: r=0.376) and relapse (CD3: r=-0.408; CD20: r=-0.355; CD45: r=-0.354) have been demonstrated. Only CD3 was reported as predictive biomarker of relapse in CC (ANOVA, t-Student, p<0.05). Conclusions: Major differences in the cellular immune response among patients with cervical cancer with and without relapse within three and five years have been demonstrated. CD3 may be used as potential prognostic biomarkers, whereas the results are promising for adjuvant immunotherapy.

Corresponding author: Eugen Ancuta, MD, e-mail: eugen01ro@yahoo.com

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15. Utero-adnexal damage in septic abortion. Histopathological study on 91 cases

M. Biris, Mihaela Moldovan, D. Pascut, A. Motoc

Septic abortion represents the main causes of abortion-induced maternal death. Hysterectomy may represent a beneficial therapeutic solution for septic abortion, nevertheless with irreversible effects on a woman's reproductive condition. The study analyzes the anatomopathological damage found in ninety-one patients hospitalized for septic abortion. The patients were admitted to the "Dr. D. Popescu" Clinical Hospital, Timisoara, between 1980-1989 and 1999-2008; hysterectomy was performed in all the cases to eliminate uterine sepsis responsible for the emerging complications.

Corresponding author: Marius Biris, MD, PhD candidate, e-mail: marius308@yahoo.com

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16. Immunohistochemical aspects of endometrial glands in dysfunctional uterine hemorrhage

V. Gheorman, Monica Banita, Anca Patrascu, Lavinia Maria Gheorman

The authors present a specific aspect of the modifications of the endometrium in dysfunctional uterine hemorrhages that is the behavior of the endometrial glands. These glands are studied from a immunohistochemical point of view, regarding both the normal endometrium (inclusively at the age of two years) and the endometrium in dysfunctional uterine hemorrhages. The antigens used were VGEF and PCNA. The result was a different reaction of the glandular structures to these antigens in the cases of patients with dysfunctional uterine hemorrhage.

Corresponding author: Valeriu Gheorman, MD, PhD, e-mail: valeriu_gheorman@yahoo.com

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17. Acquired aplastic anemia: correlation between etiology, pathophysiology, bone marrow histology and prognosis factors

Amelia Gaman, G. Gaman, Adriana Bold

Aplastic anemia is a clonal disease of stem cell characterized by peripheral blood pancytopenia with hypocellular bone marrow. In most cases acquired aplastic anemia is an autoimmune, T-cell mediated disease (hematopoiesis is mediated by a population of CD8+ T-cells which produce inhibitory cytokines - TNF-alpha, IFN-gamma, IL-6 which suppress hematopoiesis by affecting the mitotic cycle and cell killing by inducing apoptosis). In some cases radiation, medical drugs and chemicals, viruses induce depletion of hematopoietic stem cells by direct toxicity; immune diseases induce complex immune reactions leading to bone marrow failure. Symptoms and signs are represented by fatigue, pallor induces by anemia, infections induce by neutropenia, and bleedings induce by thrombocytopenia. In peripheral blood is present pancytopenia and bone marrow are characterized by hypocellularity, fat cells hyperplasia, residual lymphocytosis, plasmocytosis and mastocytosis. The aim of this study was to establish the correlation between etiology, pathophysiology, bone marrow histology and negative prognosis factors at 16 patients with acquired aplastic anemia (seven with severe aplastic anemia and nine with moderate aplastic anemia) hospitalized in Clinic of Hematology from Craiova between 2003-2008. Eight cases presented idiopathic aplastic anemia and eight cases secondary aplastic anemia (two of them with pure red cell aplasia). Conclusions: The unfavorable evolution, correlated with etiology and pathophysiology, had been seen at the patients with severe idiopathic aplastic anemia and severe secondary aplastic anemia associated with viral infections and insecticides exposure. Pure red cell aplasia was associated in our study with B19 parvovirus infection or malignant thymoma. The negative prognosis factors in acquired aplastic anemia, correlated with laboratory findings and a low survival, were: severe neutropenia, platelets count less than 10 000/micro-L, corrected reticulocytes less than 1%, hypocellularity of bone marrow <10%, persistence of pancytopenia at 30 days after initiating therapy.

Corresponding author: Amelia Gaman, MD, PhD, e-mail: gamanamelia@yahoo.com

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18. Contributions to myometrium study in uterine-tubal junction

M. C. Neamtu, R. L. Neamtu, Elena Taina Avramescu, Maria Vrabete, Lucia Mirela Calina, I. Mindrila

Complex coordinated contractions of the tubal musculature are thought to be important for movement of the ovum from the distal end to the proximal end of the tube, while at the same time aiding in the movement of sperm from the proximal end to the distal end of the oviduct. Studies of the anatomy and the physiology of the uterine-tubal junction (UTJ), with a main concern for the muscular pattern and the secretory activity of this part of the tube, in relation with the hormonal and nervous control, can play an important role in understanding and impairment of infertility. Related to these aspects, the purpose of our research is mainly to identify the determining factors in maintaining a morphological and structural balance between contractile items and extracellular matrix items within uterine myometrium, particularly uterine-tubal junction. For this reason, the present study includes analyses of anatomical sections within uterus and uterine tubes extracted from patients during therapeutic surgeries. Thirty anatomical pieces from patients aged 23-37-year-old (uterus and tubes) were used to perform microanatomical sections, 10 pieces for each pathology identified, namely leiomyofibroma, leiomyofibroma with pregnancy, ectopic pregnancies. At the same time, the study proposes a statistic and mathematic analysis of the cases with uterine-tubal junction pathology in Oltenia region within a period of 10 years. The novelty of the study is represented by the identification of certain continuity ratios between myocyte fascicles and average tunica of arteries and arterioles, which explains the existence of "vascular units" determined by myometrial structures. Moreover, the stereo-distribution of "vascular myometrial units" explains the existence of a plexiform cavernous network, which enables many authors to describe numerous barely individualized myometrial tunicas. These units are rich in orthosympathetic vegetative innervations that might be responsible for the unfavorable evolution of circulatory myometrial system in postpartum. Considering all these observations, it is highly necessary to reconsider the structure of the uterine wall and, particularly of uterine-tubal junction.

Corresponding author: Cristian Neamtu, MD, PhD, e-mail: drcristianneamtu@yahoo.com

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19. Ultrastructural modifications at the level of marginal periodontium in the case of incorrect dental reconstruction

Adriana Pirte, Ligia Vaida, Alina Venter, D. Slavescu, G. Teseleanu, Mariana Muresan, Otilia Micle, Gabriela Mutiu

Our study focused on the evolution of the marginal periodontium inflammatory process caused by an incorrect dental reconstruction. Our research studied a control group and a group of patients having traumatic and inflammatory lesions in different stages of evolution. A pronounced rarefaction of the junction desmosome structures as well as an inflammatory process pointed out by the presence of macrophages, neutrophils, Langerhans' cells, and mastocytes. The presence of altered fibroblasts and collagen fibers in the electron microscopic sections of vascular lesions represents microscopic signs of the inflammation and support the theory of local immunoglobulin synthesis.

Corresponding author: Adriana Pirte, DDS, PhD, e-mail: pirteadriana@gmail.com

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20. Anatomy of the reflected ligament of the inguinal region

R. Shane Tubbs, Jenny Gober McDaniel, Amanda M. Burns, Anjali Kumbla, Tiffany D. Cossey, Nihal Apaydin, A. Comert, H. I. Acar, I. Tekdemir, M. M. Shoja, M. Loukas

Background: There is a paucity in the literature regarding the reflected ligament. Therefore, the present study was performed in order to further elucidate this anatomy. Material and Methods: Eighteen formalin-fixed adult cadavers (35 sides) underwent dissection of the medial inguinal region. The reflected ligament was observed for and when identified, its dimensions were measured. Results: 83% of sides were found to have a reflected ligament. These were identified in 16 male and 13 female bodies. The size and shape for the reflected ligaments were variable but overall, triangular in nature. In general, the reflected ligament was found to extend from the lacunar and medial inguinal ligaments and extended obliquely toward the midline at an approximate 450 angle to insert near the linea alba. Two ligaments (6.9 %) were identified that interdigitated with the contralateral reflected ligament. The medial and lateral lengths of the ligament had a mean measurement of 2.28 and 2.58 cm. The base of the reflected ligament had a mean of 2.52 cm and the height of this ligament was found to have a mean of 2.56 cm. The mean area of the reflected ligament was calculated as 2.93 square-cm. There was no statistically significant difference between right or left sides or between genders. Conclusions: The reflected ligament was identified in the majority of our specimens and this structure usually contributed to the formation of the posteromedial wall of the external inguinal ring. Therefore, this fact should be included in future descriptions of this ligament.

Corresponding author: Richard Shane Tubbs, MD, PhD, e-mail: rstubbs@uab.edu

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21. Primary malignant non-Hodgkin's lymphomas of salivary glands

Alexandra Faur, Elena Lazar, Marioara Cornianu, Alis Dema, Codruta Lazureanu, Anca Muresan, Sorina Taban

We evaluated the medical record of patients with salivary gland neoplasms diagnosed at Timisoara City Hospital from 2002 to 2009. A study has been carried out for seven years on 204 cases of salivary gland tumors and only two cases of salivary gland lymphomas were diagnosed. The two cases were females of 71- and 49-year-old, respectively. The formalin-fixed paraffin-embedded tissue samples were cut in 4 micrometers thick sections and stained with Hematoxylin and Eosin. The primary monoclonal antibodies for the immunohistochemical analysis were the followings: LCA (2B11, Dako), CD20 (L26, Dako), cytokeratin (MNF116, Dako), p53 (DQ-7, Dako), and PCNA (PC-10, Dako). The histopathology and immunohistochemistry suggested in the first case a low-grade diffuse large B-cell mucosa associated lymphoid tissue lymphoma and in the second case a high-grade extranodal marginal zone B-cell lymphoma.

Corresponding author: Alexandra Faur, MD, PhD, e-mail: alexandra_pantu@yahoo.com

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22. Differential diagnosis issues in a case of gastric carcinoma associated with leukemoid reaction

C. Bosoteanu, Madalina Bosoteanu, Mariana Aschie

Gastric tumors share many characteristics, making a definitive diagnosis challenging. Gastric adenocarcinomas represent 90% of malignant stomach tumors, meanwhile the frequency of gastric lymphoma range between 1-5% of all gastric cancers. Gastric carcinoma bears resemblance with particular forms of non-Hodgkin's lymphoma of the stomach, not only in morphological presentation, but also in clinical configuration and laboratory tests. We report a case of gastric carcinoma with abnormal hematological picture dominated by leukemoid reaction and peculiar histopathological aspect. Pleomorphism of neoplastic cells and distinct arrangement of these give rise to the need of differentiation between a carcinoma and a non-Hodgkin's lymphoma of the stomach. On immnohistochemical grounds, we succeeded in our action of segregation between the two lesional entities and we establish as definitive diagnosis that of poorly differentiated gastric adenocarcinoma. Additionally, leukemoid reaction proved to be a manifestation of a bone marrow metastasis from gastric cancer.

Corresponding author: Catalin Bosoteanu, MD, e-mail: cbosoteanu@yahoo.com

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23. Correct complete denture rehabilitation, a chance for recovering abused tissues

Iuliana Babiuc, Mihaela Pauna, Madalina Adriana Malita, Simona Georgiana Ariton, Maria Damian, Vasilica Ungureanu, Anca Petrini

The prosthodontic treatment must provide for the edentulous patients bio-functional prosthetic restorations, bio-prophylactic for the surrounding tissues. In this aim, an edentulous patient must be submitted to a methodical clinical examination in order to establish the quality of hard and soft tissues, which will indicate the degree of difficulty of the prosthetic treatment. Additional investigation as a microbiologic examination and cephalometric radiographs can be useful in a modern investigation. In our daily practice, we are rarely confronted with a normal morphology of the denture bearing oral structures. The problem of managing abused tissues in a patient with morphologic abnormalities due to faulty prostheses is sometimes difficult to solve. Preventing the deterioration of oral status must be a condition in providing a chance for the success of the following rehabilitations, mainly in the situation when the complete edentulousness succeeds in a young or middle age patient.

Corresponding author: Iuliana Babiuc, DDS, PhD candidate, e-mail: iuliba@yahoo.com

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24. Giant wing sphenoid meningioma with principal manifestation depression

Adela Magdalena Ciobanu, M. Gh. Lisievici, Teodora Camelia Coman, Gh. V. Ciubotaru, Alina Draghia, Fl. Draghia, A. A. Ciucu

A 68-year-old woman with no previous mental illness presented with a three-month history of decreased energy, fatigue, feelings of hopelessness, pessimism, difficulty concentrating, and persistent feelings of "emptiness", worthlessness, insomnia, appetite loss, diminished functionality. The patient's neurological examination was normal. She was diagnosis with major depressive disorder (MDD) by Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria and received psychiatric treatment. Resistance at therapy leaded at cerebral axial computed tomography (CT) indication. Cerebral CT-scan revealed an intracranial expansive mass (EPIC) located in frontal-temporal (F-T) right lobe, size 42/45/66 mm, hyperdense lesion, without peri-lesional edema, inserted on the great sphenoid wing, image suggestive for meningioma. MRI confirmed the presence of tumor and angiography showed the arterial source of the meningioma. The neurosurgical intervention removed successfully the tumor. Grossly examination revealed a giant tumor with a maximal diameter of 7 cm. The histological aspect of the tumor was highly representative for the diagnosis of meningioma. Patient mental status was evaluated at baseline, in preoperative period and postoperative period and had been using Hamilton Depression Rating Scale (HDRS) - 17 items version, Clinical Global Impression Scale (CGI), and Global Assessment of Functioning (GAF). After neurosurgical intervention, functioning was improving with completed remission of depression symptoms at six-month postoperative evaluation. Conclusion: Most meningiomas are slow growing and many are found incidentally. The decision to perform a cerebral CT-scan depends on the clinician's degree of suspicion that a tumor is present. A first depressive episode is a clinical condition with principal indication for cerebral CT-scan.

Corresponding author: Adela Magdalena Ciobanu, MD, PhD, e-mail: adela.ciobanu@gmail.com

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25. The importance of histopathologic aspects in the diagnosis of dissecting cellulitis of the scalp

Daciana Elena Branisteanu, Andreea Molodoi, Delia Ciobanu, Aida Badescu, Loredana Elena Stoica, D. Branisteanu, I. Tolea

Dissecting cellulitis of the scalp or dissecting folliculitis also known as "perifoliculitis capitis abscedens et suffodiens" (PCAS), is a rare, severe and distinct dermatological disease. It most probably occurs because of follicular occlusion via hyperkeratosis, having the same mechanism of acnea conglobata and hidradenitis suppurativa. These dermatoses may be associated or may have an isolated evolution. PCAS is one of the primitive cicatricial alopecia of neutrophilic type (with pustules). What is characteristic for the histopathologic picture of the disease is the deep inflammatory infiltrate, placed at the reticular derm or hypoderm level. The initial perifolliculitis evolves towards forming profound abscesses and the destruction of polysebaceous follicles because of granuloma, usually lymphoplasmocitary and with gigantic cells. Here is the case of a 24-year-old male with records of acne conglobata and cicatricial alopecia of the scalp, with relapsed inflammatory nodular lesions on the surface of the alopecic plaques and follicular pustules on their margin. The patient had followed before hospitalizing a systemic treatment with antibiotics (azithromycin, tetracycline, ciprofloxacin, in therapeutic schemes that the patient cannot mention, but anyway of short time) and after that a treatment with retinoids (isotretinoin, 20-30 mg/day, in two successive therapies of one month each). The evolution of the disease under these treatments was with outbreaks and short times of remission of the acne lesions and nodular lesions of the scalp. The clinical diagnosis of PCAS is difficult, especially in the initial stage of the disease, as it was the case of the patient presented here. We underline the importance of a correct history of the disease, of the complete clinical exams and the need of paraclinical investigations (histopathologic exam from the lesional biopsy - microscopy and immunohistochemistry) in order to come with a positive diagnosis of PCAS and a differential one.

Corresponding author: Daciana Elena Branisteanu, MD, PhD, e-mail: debranisteanu@yahoo.com

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26. Unusual coexistence of a variant abductor digiti minimi and reversed palmaris longus and their possible relation to median and ulnar nerves entrapment at the wrist

G. P. Georgiev, L. Jelev

During routine anatomical dissection of the left upper limb of a 73-year-old female cadaver, a unique coexistence of variant muscles was found. In the forearm region, a largely developed reversed palmaris longus was discovered. Its short distal tendon was in close relation to the median nerve. In the neighboring hypothenar region, an unusual abductor digiti minimi was also observed. Its muscular body was composed of two portions - medial and lateral one, arising from the reversed palmaris longus tendon. The lateral portion passed over the ulnar nerve and artery in the canal of Guyon. In the literature, there are descriptions of entrapment neuropathies caused by either reversed palmaris longus or variant abductor digiti minimi. Here, for the first time we describe a coexistence of these variant muscles and suggest it as a possible, even rare, cause of both the median and ulnar nerves entrapment and ulnar artery thrombosis.

Corresponding author: Georgi P. Georgiev, MD, e-mail: georgievgp@yahoo.com

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27. A nodular hyperplasia of the thymic epithelium (so-called microscopic thymoma)

R. Cornea, Elena Lazar, Alis Dema, Diana Herman

We investigate a case of nodular hyperplasia of the thymic epithelium which was incidentally, microscopically discovered. Macroscopically there was no sign of tumor and the thymus was surgically removed for the therapy of the clinical symptoms of the myasthenia gravis worsened in two years of evolution. Histological in a general appearance of an involuted thymic tissue, a small nodular epithelial proliferation was identified. The epithelial proliferation was classified as A-type in the WHO histological classification of the thymic epithelial tumors. Generally, these microscopic thymomas range from 0.2 mm to 0.4 mm in size that corresponds to our finding that measured 0.25/0.35 mm. This lesion was singular; on additional sections examined, we did not find other areas. Even so, there is a tight connection between the myasthenia gravis, thymomas and these microscopic thymomas, the development of a thymoma from this lesion has not been proven.

Corresponding author: Remus Cornea, MD, PhD candidate, e-mail: cornearemus@yahoo.com

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28. Immunoproliferative small intestinal disease versus colonic monoblastic sarcoma in a 2-year-old boy

Ingrith Miron, Doina Mihaila, G. Aprodu, L. Miron, P. Plamadeala, Stefana Maria Moisa

The authors present a case of colonic monoblastic sarcoma, previously treated for other digestive abnormalities (malabsorbtion, Hirschprung's disease). Important similitudes with immunoproliferative small intestinal disease (IPSID) lymphoma were demonstrated for this patient (male, 2-year-old). His main admission complaints were failure to thrive, recurrent episodes of enterocolitis and malabsorbtion syndrome. Some particularities of this case are the young age and the extremely rapid development of the malignant disease in a patient with no previous signs of acute non-lymphoblastic leukemia. The initial diagnosis was of malabsorbtion syndrome, based on the clinical exam at presentation, and then the patient was thought to have a form of Hirschprung's disease, due to a functional intestinal disorder (slow transit). After the necropsy, pathologists diagnosed an immunoproliferative small intestinal disease, and four years later, they performed a more appropriate pathological exam, which explained better clinical symptoms associated to this complex case.

Corresponding author: Ingrith Miron, MD, PhD, e-mail: lucmir@gmail.com

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29. Right carinal pneumonectomy for a delayed diagnosis

Cl. Nistor, Natalia Motas, C. Motas, Daniela Ion, M. Davidescu, Florina Vasilescu, T. Horvat

The authors present the case of a male patient misdiagnosed with right upper lobe tuberculosis and repeatedly treated for this in the last two years, without response. In our institution, the source of the hemoptysis proved to be a pulmonary carcinoma, which in its evolution involved the carina and the last tracheal ring. Right carenal pneumonectomy with two tracheal ring resection is performed, with reconstruction of the airway by anastomosing the main left bronchus to trachea. The resection involved also the azygos vein and the lateral wall of the superior vena cava (angioplastic resection), the vagus nerve and the pericardium, the last are being reconstructed with synthetic mesh. Histopatologic diagnosis is squamous cell carcinoma moderately differentiated. The right tracheal sleeve pneumonectomy was the therapeutically choice for a middle-aged patient with recurrent hemoptysis and retrostenotic lung destruction.

Corresponding author: Claudiu Nistor, MD, PhD, e-mail: ncd58@yahoo.com

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30. The histopathology analysis of the diffuse sclerosing variant of the papillary carcinoma of the thyroid: a distinctive and rare form

Camelia Doina Vrabie, Dana Terzea, Angela Petrescu, Maria Waller

Diffuse sclerosing variant (DSV) is a rare variant of papillary thyroid carcinoma (PTC) and its features have not yet been fully characterized. The aim of this case report is to analyze the immunohistochemistry profile of this disease and to highlight this rare entity. We analyzed the histology and immunohistochemistry of a female patient admitted in the Surgery Department of the "Sf. Ioan" Emergency Hospital, Bucharest, in April 2008. We especially used a wide panel of antibodies (Thyroglobulin mono, Thyroglobulin poly, Ki-67, TTF 1, Cytokeratin 19, Cytokeratin 34betaE12, and p63) in order to point out the follicular origin of the cells and to investigate the extensive squamous metaplasia lesions. The immunohistochemistry (IHC) was performed on 3 microns thick sections from 10% formalin-fixed paraffin-embedded tissues, according to the indirect tristadial Avidin-Biotin-Complex method. Our case report reveals that the DSV of PTC has distinctive pathologic features and its diagnosis importance is suggested by the high incidence of recurrence after operation.

Corresponding author: Camelia Doina Vrabie, MD, PhD, e-mail: camianapat@yahoo.com

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31. Ileal iterative spontaneous perforation from foreign body granuloma: problems of histopathologic diagnosis

V. Surlin, E. Georgescu, Violeta Comanescu, S. S. Mogoanta, I. Georgescu

Spontaneous ileal perforation is a very rare cause of peritonitis. It occurs, in most of the cases, as a complication of Crohn's disease or intestinal tuberculosis. We present the case of a 23-year-old female patient with multiple surgical interventions during the last year, for iterative ileal spontaneous perforation with generalized peritonitis of which cause was initially assigned to intestinal tuberculosis. Actual episode of generalized peritonitis was determined once again by an ileal perforation of 5 mm at 70 cm from the ileo-cecal valve situated on a suture scar. Distally, a bowel stricture and a non-complicated Meckel's diverticulum were also noted. We performed an enterectomy including all three aforementioned lesions with end-to-end anastomosis. The histopathologic report revealed granulomatous giant-cellular inflammation in the margins of the perforation. The tuberculous etiology was questioned because of the negativity of the PCR-test and multiple recidives of perforation under specific anti-tuberculous medical therapy. The discovery of some rests of non-resorbable suturing material in a granuloma on an ancient enterorraphy scar in the resected specimen, finally established the cause. The granulomatous giant-cellular inflammation of foreign body is a rare cause of ileal perforation. The histopathologic differential diagnosis is difficult needing correlation with clinical data. Usage of resorbable suture material avoids that risk.

Corresponding author: Valeriu Surlin, MD, PhD, e-mail: vsurlin@gmail.com

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32. In memoriam Prof. Dr. Doc. Gioconda Dobrescu (1926-2009)

Irina-Draga Caruntu

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Corresponding author: -

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